In general, the reference values of diagnostic test parameters are specified based on the values of 95% confidence intervals of those parameters measured in healthy subjects. As heart size varies according to sex, there are sex-related differences in the reference values of echocardiographic parameters. There have been attempts to minimize the variability in the reference values of echocardiographic parameters worldwide by correcting for age-related, sex-related, and body size-related differences. This short review describes the current status and issues regarding the reference values of echocardiographic parameters and discusses the findings of research aimed at resolving these issues.

Echocardiography is used worldwide to evaluate cardiac size and function. To determine what values are abnormal, it is essential to establish normal reference values for echocardiography. The current guidelines for chamber quantification specify normative values for cardiac chambers and recommend that gender and body size be taken into account. However, these normative data were established using databases for which a variety of measurement methods were used and the majority of subjects consisted of Whites in Europe and the United States. However, several regional studies from other countries suggest that cardiac size varies globally. To overcome these limitations, the Normal Reference Ranges for Echocardiography study and the World Alliance of Societies of Echocardiography Normal Values study have recently been conducted to examine similarities and differences in cardiac chamber size and to establish normal reference values while taking worldwide diversity into account. The results from these studies have demonstrated that standardization of normal reference values for cardiac size is important. This review article aims to summarize the current status of normative echocardiographic values for cardiac chamber size.

Despite recent advances in imaging for myocardial deformation, left ventricular ejection fraction (LVEF) is still the most important index for systolic function in daily practice. Its role in multiple fields (e.g., valvular heart disease, myocardial infarction, cancer therapy-related cardiac dysfunction) has been a mainstay in guidelines. In addition, assessment of LVEF is vital to clinical decision-making in patients with heart failure. However, notable limitations to LVEF include poor interobserver reproducibility dependent on observer skill, poor acoustic windows, and variations in measurement techniques. To solve these problems, methods for standardization of LVEF by sharing reference images among observers and artificial intelligence for accurate measurements have been developed. In this review, we focus on the standardization of LVEF using reference images and automated LVEF using artificial intelligence.

Global longitudinal strain (GLS) is a robust and sensitive marker of left-ventricular systolic function, reflecting longitudinal shortening of the ventricle. A growing body of evidence indicates its superiority in identifying subclinical, early alterations in cardiac function compared to traditional markers, such as ejection fraction. Therefore, there is a growing demand to assess GLS in clinical settings, but limited availability on how to obtain GLS accurately and appropriately in the current literature. This review summarizes key aspects of GLS measurement, including image acquisition, post-processing, and training/experience needed to facilitate the clinical implication with standardization.

Advanced age is widely recognized as a key risk factor for incident cardiovascular disease. The age-associated changes in cardiac properties alter the substrate on which cardiovascular disease is superimposed in various ways, and thus affect the development and manifestations of cardiovascular disease (CVD) in the elderly. However, it is still unclear whether age-related cardiac alteration is attributed to aging itself or whether it is secondary to other acquired cardiovascular risk factors. Understanding the association between aging and cardiac functional remodeling might provide insight into the pathogenesis of cardiovascular aging and may help inform possible preventive strategies for CVD in older individuals. Speckle-tracking echocardiography enables the objective and quantitative assessment of subtle myocardial alterations that are undetectable with conventional echocardiography, and has excellent feasibility and reproducibility. Left ventricular (LV) global longitudinal strain, a sensitive measure of LV systolic dysfunction, was found to be an independent risk factor for cardiovascular morbidity and mortality. More recently, deformation imaging has been employed to assess right ventricular (RV) and atrial performance, and impaired RV and atrial strain predict unfavorable outcomes in various clinical settings. This article reviews the association between aging and changes in myocardial strain values and describes future perspectives.

Ultrasound-based diagnostic criteria for fatty liver were published on the website of The Japan Society of Ultrasonics in Medicine in May 2019. Here, tips and tricks for ultrasound-based diagnosis of metabolic syndrome including fatty liver are presented. First, it should be noted that the pathological definition of fatty liver was changed as follows: the standard rate of lipid droplets in hepatocytes was lowered from “30% or more” to “5% or more” by the consensus of some academic societies. In addition, special ultrasound examination techniques are required in patients with metabolic syndrome because of abdominal bloating and subcutaneous/intraperitoneal fat accumulation. The key points of ultrasound-based diagnosis of metabolic syndrome are as follows: (i) elimination of preconceptions, (ii) appropriate compression of transducer and breathing control, (iii) effective use of intercostal scanning, (iv) try changing the ultrasound machine settings, and (v) effective use of patient position changes. We hope the information provided will be useful in your daily medical practice.

Injection for knee joint pain caused by osteoarthritis has conventionally been performed via intracapsular injection. However, with the spread of ultrasound diagnosis and treatment in the field of musculoskeletal disorders, the conventional wisdom is changing as we can see pathologies of diseases that could not be seen with conventional diagnostic imaging tools and perform interventions that could not be performed with conventional imaging tools. The key to musculoskeletal ultrasound for knee pain is to understand the ultrasonographic anatomy, and it is important to understand the anatomy of the laminar structures. In the case of medial knee pain caused by osteoarthritis of the knee, the tenderness points can be accurately identified and ultrasound-guided injections can be accurately performed in the same area to understand the pathophysiology and lead to new conservative therapies. This article describes the diagnosis of osteoarthritis of the knee and ultrasound-guided injection for medial knee pain.

Many patients visit outpatient clinics suffering from tumors of the body surface and the neck. Ultrasonography is very useful because it is noninvasive and can provide information in real time. There is a complicated array of various tissues in the neck including blood vessels, nerves, muscles, salivary glands, and so. It is important for us to understand the anatomy when performing ultrasonography. It is necessary for us to master the screening examination to scan the whole neck systematically to understand the anatomy. We select several parts of basic images in the neck such as the thyroid gland, common carotid artery, internal jugular vein, submandibular gland, mental region, parotid gland, and outside neck. Scanning results of these parts should be recorded. Many lymph nodes are depicted as flat, oval, low echoic masses of the clear border when we carefully scan the whole neck using ultrasonography. In the central part of the normal lymph node, we recognize a small, high echo part called the fatty hilum. We detect the bloodstream along the fatty hilum on color Doppler imaging. This normal lymph node structure is destroyed in metastatic lymph nodes of head and neck cancer as they swell. Therefore, ultrasonography allows the differential diagnosis of normal lymph nodes and metastatic lymph nodes. Other tumors often appearing in the neck include thyroid gland tumors, salivary gland tumors, neurogenic tumors, lipomas, cystic tumors, and hemangiomas. Since there are characteristic ultrasound images of each tumor type, it is necessary to discern the shape, onset site, and internal bloodstream in detail for accurate diagnosis. Inspection and palpation help the diagnosis of body surface and head and neck tumors.

Pfeiffer syndrome－which is characterized by craniosynostosis, mid-face hypoplasia, and broad deviated thumbs－is classified into three clinical subtypes based on the severity of the phenotype. Pfeiffer syndrome type 2 is the most severe form, usually leading to death during early infancy. Therefore, an accurate diagnosis of Pfeiffer syndrome and appropriate counseling are critical. However, diagnosing Pfeiffer syndrome prenatally using ultrasonography alone is difficult because the differential diagnosis is complicated. Here, we report a case of Pfeiffer syndrome type 2 diagnosed in the second trimester using three-dimensional computed tomography complemented with ultrasonography. This report discusses the usefulness of computed tomography for the prenatal diagnosis of Pfeiffer syndrome.

In Cowden syndrome, benign breast conditions such as ductal hyperplasia, intraductal papillomatosis, adenosis, and fibroadenomas as well as cancers can occur, which may be difficult to distinguish. This case was a 35-year-old Japanese woman who had a history of thyroid follicular carcinoma and uterine cancer. She had multiple breast lesions and had been followed up with ultrasonography for about 19 years. She noticed a new lump in her right breast on her own, and ultrasonography showed a new intracystic tumor among various lesions, which was diagnosed as suspected cancer using vacuum-assisted breast biopsy (VAB). Contrast-enhanced magnetic resonance imaging showed a lesion on the contralateral side that was also suspected to be malignant. Bilateral mastectomy, bilateral sentinel lymph node biopsy, and bilateral axillary dissection were performed. She received adjuvant chemotherapy and radiation therapy, and she is taking anastrozole. Multi-gene panel testing showed germline pathological variants of the PTEN gene.